Problem statement and aims: A number of health systems have described the difficulties of ensuring coherent, network-wide approaches to patient safety across multiple care settings. A community healthcare organization undertook a system-wide quality initiative to reduce hospital-acquired infections and improve patient safety through a bathing and oral care initiative. It was agreed that all healthcare partners within the system would support the initiative in meaningful measurable ways. A number of hospital-based inpatient and ambulatory care departments across the system collaborated to work with the Magnet core committees and utilize the existing shared governance structure to contribute to patient safety. The challenge for the ambulatory care units included identifying measurable opportunities to participate in this very important quality initiative.

The aim of the ambulatory care project was to ensure patient education and pre-procedure readiness with a focus on education regarding the importance of daily bathing and oral care 2 to 4 times daily during hospitalizations.

Background: A system-wide healthcare quality project was initiated with the aim of decreasing hospital-acquired infections (CLABSI, CAUTI, HAPI) as well as near epidemic numbers of community acquired infections including C-Diff. The National Database of Nursing Quality Indicators (NDNQI) identified hygiene as the #1 missed inpatient care/treatment. The system-wide initiative is the first to be led by the nursing Magnet council and implemented using a shared governance approach that encompasses every department in the system.

Methods: The ambulatory care department worked with the four core Magnet committees to develop specific pre-procedure education and immediate pre-procedure oral and cleansing measures. The health system goal is greater than 75% compliance with once daily bathing and evidence-based oral care. The project will also include monitoring hospital-acquired infections rates and patient satisfaction related to bathing. Specific ambulatory care outcomes include: 1) provide education to ambulatory care patients pre-hospitalization on the importance of bathing and oral care prior to and during hospitalization, 2) educate ambulatory care patients immediately pre-procedure on the importance of pre-procedure bathing and oral care, and 3) ensure, when appropriate, pre-procedure hygiene and oral care is completed in the pre-procedural ambulatory care surgical areas.

The project timeline is as follows:
• 2019 Q1: conception and planning phase
• 2019 Q2: implementation
• 2019 Q3: data gathering
• 2019 Q4: continued data gathering and assessment
Conclusions: This project is currently in progress and we will have data to include if accepted to present at AAACN.

References
1. Huang, S. S., Septimus, E., Kleinman, K., Moody, J., Hickok, J., Heim, L., ... & Hayden, M. K. (2019). Chlorhexidine versus routine bathing to prevent multidrug-resistant organisms and all-cause bloodstream infections in general medical and surgical units (ABATE Infection trial): a cluster-randomised trial. The Lancet.
2. Kanzigg, L. A., & Hunt, L. (2016). Oral health and hospital-acquired pneumonia in elderly patients: a review of the literature. American Dental Hygienists' Association, 90(suppl 1), 15-21.

Purpose: A collaborative effort was undertaken in a large primary care system to align with current guidelines for management of viral conjunctivitis from the Center for Disease Control and Prevention and the American Academy of Ophthalmology as well as the promotion of antibiotic stewardship.

Description: Research indicates that most cases of conjunctivitis (pink eye) are caused by a virus and are typically a self-limiting illness, which means prescription antibiotic treatment is ineffective and unnecessary (O’Brien, Heng, McDonald, & Raizman, 2009; Holz et al., 2017, American Academy of Ophthalmology, 2017). The expectation for antibiotics to cure a viral infection leads to increased costs and delays in returning to work, school, and day care. Unnecessary prescribing of antibiotics leads to antibiotic resistance and gives a false sense of hope to patients who believe it will effectively treat the infection (Holz, et al., 2017). Research and society guidelines showed current practice of prescribing topical antibiotics in outpatient nurse protocols for conjunctivitis was not consistent with recommendations. Advising absence from school, day care, and/or work until improved is not a requirement, unless secretions cannot be managed.
An update in care processes was needed to align with the evidence and state department of health recommendations for the treatment of conjunctivitis. This update required collaboration with multiple state health agencies and schools with widespread communication to the public about this practice change. Communication was vital to ensure alignment with and understanding of best practice for conjunctivitis care. During the pre-implementation timeframe, the institution was undergoing a practice convergence process for primary care, which allowed for organizational collaboration. Key stakeholders were identified across the healthcare system and were represented in the project group. Multiple departments and institutional committees were involved in the process. This assisted in achieving internal support for promoting antibiotic stewardship with appropriate prescribing for patients. Additionally, a number of internal resources including guidelines, protocols and electronic health record updates were reviewed and updated by the project group. A multidisciplinary team including public affairs representatives was formed to ensure accurate communication was provided in appropriate timeframes to all stakeholders. A detailed communication plan was developed for consistent messaging including a subgroup that identified patient education materials that required an update to match the practice change. Additional resources were developed to support healthcare providers within and external to the organization.

Evaluation/outcome: The outcome was clear and consistent messaging for care of conjunctivitis to both healthcare providers, patients, and the communities at large with an anticipated decrease in prescribing antibiotics for viral conjunctivitis

Future implication and learnings: It was identified that state legislative changes were needed for approval related to day care rules and standards. Further work is essential to update legislation to reflect the conjunctivitis practice change.

As a Magnet organization and an institution that values feedback from families, our organization utilizes a service to survey families after their visits. These surveys ask Likert-type questions with five (5) focused nursing-only questions, with about 5-10 additional questions related to their overall experience with the provider, care team, facility, and system in general. These scores help to drive specific organization initiatives around introductions, care coordination, access, and appointment availability and provide insight to how families are feeling regarding their care. We noted very low scores in our nursing-specific questions across nearly every specialty and location. Concerned that these scores seemed incongruent with the comments, provider scores and general feeling of the teams, leadership and the organization additional investigation was done to ensure accurate data was being captured. During this investigation journey, we noted several opportunities. The first opportunity was that every clinic, regardless of nursing presence, was being surveyed. We were able to remedy this and exclude specific clinics that did not staff nurses from receiving these questions. The second opportunity was with our introductions, specifically with the support team (medical assistants) and nurses. We launched an informal campaign across ambulatory care to encourage introductions of name, role, and then introduction of name and role of the next up team member. This was in an effort to draw awareness to the role of each team member in the visit and enhance the family’s ability to answer accurately related to the nursing components of the visit. Finally, we realized families did not have the option to “opt out” of the nursing questions. This meant that if they did not see a nurse during their particular visit, they were still forced to answer the questions related to interactions with a nurse. We worked with our survey vendor to add a “gate” question that allowed families to skip the questions related to nursing if they did not see a nurse during their visit. At this point, we saw nearly a 20% increase in composite scores across all areas. Families were finally able to accurately report their interactions, and we were able to accurately capture their feedback more closely related to nursing interactions. This was a sustained gain over the course of the year—an additional four (4)-month time frame. Additional work is ongoing, specifically related to continuing to creatively solve how to survey related to ambulatory care-specific work.

The 2010 Institute of Medicine’s foundational report on the future of nursing centered on several key areas for nursing practice: 1) nurses should practice to the full extent of their education and training; 2) nurses should achieve higher levels of education and training; 3) nurses should be considered full partners with physicians and other healthcare professionals; and 4) nurses are well-placed to support workforce planning and policy, especially regarding data collection and information infrastructure. The much-anticipated release for IOM’s 2020-2030 report will fully embrace a vision for nurses that calls them to lead change efforts and advance health with role empowerment and influence. Therefore, nurse leaders must clear a path that both supports and encourages autonomous decision-making, collaborative work, systems-thinking and research-grounded practice. The collective practice model for nurses must also support redesign work that is thoughtful and inclusive so that antiquated and rigid processes and systems are replaced with innovative, equitable, and more nimble health environments. Although a hefty lift and long road ahead, our organization’s leaders recognize the necessity of becoming a healthcare partner that constructs such a pathway for ambulatory care nurses.

In 2018, our newly erected center for advanced pediatrics consolidated several specialties and programs (more than 70 total). Our team of 2,600 physicians, 13 telemedicine, and 27 locations, and nearly 10 urgent clinics care for more than half a million children every year (we are the largest pediatric provider in our state and one of the largest in the country). Historically, we are an inpatient-focused system; only within recent years have we strategically grown in ambulatory care. During practice integrations and nurses transferring from inpatient to outpatient areas, a few key concerns consistently surfaced in feedback: 1) no formalized structure for professional practice; 2) disjointed communication from the system and between care team roles; 3) perception of system isolation (inpatient-focused events, learning, and recognition); and 4) little-to-no growth opportunity in existing nurse role.

This open dialogue offers us opportunity to begin foundational work around ambulatory care nurses and healthcare teams – specifically, creating a shared leadership infrastructure, hosting nurse cafes to socialize system initiatives, partnering with our research department to initiate projects and quality workgroups, and reviewing workforce, residencies, and professional development pathways (education-BSN and certifications).

Designing and implementing such a roadmap is difficult and inexplicably challenging in any organization! As leaders, we know placing infrastructure is only one part of addressing culture. We are required to encourage collaboration alongside self-efficacy, elevate voices, work with authenticity, and keep momentum. This presentation topic is both compelling and universally meaningful to AAACN conference peers. For the first time in our organization, we as ambulatory care nurse leaders have taken part in developing our system’s nursing strategic plan. We are so very excited about this work and the impact we will make. As we look to the future, achieving ambulatory care Magnet recognition (an impossible feat a few years ago) no longer looks like a Sisyphean exercise. We expect attendees to gain insight, receive examples of successful strategies, relate to and learn from our experience, and walk away energized for the work ahead.

Our colleagues noted a knowledge deficit related to role clarity and scope of practice in the ambulatory care setting. The purpose of this work is to provide a comprehensive resource that will improve ambulatory care leadership and staff’s knowledge related to the different types of clinical team members and address how each level of licensure and education shapes opportunities and limitations. The guiding principles by which this work evolves are all roles are appreciated and valued in the practices, and all individuals are working to the top of their education and licensure to maximize value for the practice and patients while increasing employee satisfaction.

A workgroup of ambulatory care nursing professionals facilitated the project conferring with internal and external content experts. The team facilitated focus groups to assimilate appropriate content and tools in the development of the toolkit, communication, and education plan. The toolkit is comprised of three reference documents accessible to the end user through the organizational intranet: 1) scope visual summary and guide – a 30,000 ft illustration of the range of roles, functions, responsibilities, and activities members of the patient care team are educated and authorized to perform; 2) scope of practice comparison chart – by law, the scope of practice and allowable duties differ for the nurse practitioner (NP), registered nurse (RN), licensed practical nurse (LPN), medical assistant (MA), and this chart provides a snapshot comparison; 3) table of value and task matrix – a guide by team member and task to demonstrate the value of each clinical team members’ role in the practice.

Implementation of the toolkit accompanied a robust communication and education plan framing the intended use and expected outcome as teams utilize the resources to make informed decisions related practice operations. Nursing leaders reinforce the application of the toolkit for decision-making and education using modeling and coaching strategies. The focus groups and consultation with experts in the organization provided valuable insight that delivered an optimal toolkit to meet the needs of our administrative and clinical colleagues. Refinements were made based on end user feedback and ease of use to meet the goals of the project. Education was delivered by nursing leaders to 500 staff members, 75% nursing, 50% administrative staff, and 25% MD to the use of the tool.

Results are in progress, and the team delivered an evidence-based resource for ambulatory care leaders and staff to assist with role clarity in the context of hiring decisions and discussions based on practice needs related to RN vs. LPN vs. MA scope of practice. The hypothesis is that with the implementation of this toolkit turnover rates for nurses and MAs will decrease by 15%.

The centralized refill renewal center (CRC) was created as a collaboration between a primary care clinic and the outpatient pharmacy department to remove the work of handling refills from clinic staff and providers. This allows greater patient access since the work is done by the centralized refill team, allowing clinic MAs and RNs to focus on direct patient care and reducing after-hours charting for the providers. Today, the CRC services primary care and specialty clinics across the health system.

At the start, the CRC was staffed with three clinical team members, 2 RNs and 1 pharmacist. With growth, pharmacy technicians were added to the team. Currently, there are 19 pharmacy technicians, 10 RNs, and 5 pharmacists that handle refill renewal requests per protocol. Pharmacy technicians sort faxes and electronic messages from patients and providers and take phone calls. Clinical staff and pharmacy technicians can approve or deny refill request per protocol. When a medication cannot be approved by a pharmacy technician, they put the medication on a pending status, document relative information, and send clarification questions to providers and patients, allowing clinical staff to focus on work that requires clinical decision-making.
The CRC receives refill renewal requests electronically from pharmacies, telephone calls, electronic messaging through the EHR, and faxes. When questions arise, the CRC staff communicates with pharmacies, providers, and patients either electronically or by phone. To increase staff satisfaction, the CRC is piloting telecommuting, as this work does not need to be completed onsite and the staff require minimal supervision.
The CRC protocol encompasses approximately 800 medications, and of these, 460 are refillable by pharmacy technicians. The CRC refill renewal protocol is embedded in the EHR with automated identification of the last provider visit, relevant lab work, and vital signs for each medication. The protocol is vetted by a multidisciplinary steering committee made up of providers, RNs, clinic mangers, pharmacy technicians, and pharmacists.

The CRC has grown from servicing 26 clinics to over 80 clinics in the last two years without increasing FTE due to embedding the protocol in the EHR. The CRC processes over 50,000 refill renewal requests on a monthly basis. The CRC has a service agreement with all clinics to process routine refill renewal requests in two business days and urgent refill renewal requests in one business day. The average handle time per staff member is 2.8 minutes (SD 1.3 to 4.1 minutes) per refill renewal. The work completed by the CRC save 25,000 provider/clinic hours per month.

Centralizing services is an added value to a large healthcare system by standardizing workflows, meeting CMS compliance with an embedded EHR protocol, reducing provider burnout, and creating additional patient access. The CRC staff express high job satisfaction as compared to pharmacy technicians and pharmacist in a retail setting and RNs in direct patient care roles. The demand for the CRC services is high, and in the future, it is expected the CRC will service all 300 clinics in the health system.